Systems Concepts – Part 4: Systems of Care

In this forth segment of the series on Systems Concepts, we take a deeper look into the systems of care concept to understand all of the elements and organizations that are involved. We use stroke systems of care as the example. (Duration 5:48)

Notes and Resources

  • HeartRescue Project – Fosters systems of care for out-of-hospital cardiac arrest. “The HeartRescue project is designed to improve how SCA is recognized, treated and measured around the world.  The HeartRescue Project approach builds on decades of best practices at the bystander, prehospital and hospital level, combining them under one program in order to expand geographic reach.”
  • Mission: Lifeline – a program from the American Heart Association to foster systems of care for STEMI, cardiac arrest, and stroke.
  • Take Heart America – Fosters systems of care for out-of-hospital cardiac arrest.  “Take Heart America provides state-of-the-art innovative care to increase survival and brain function after cardiac arrest. We partner with communities and other nonprofits to change behaviors and implement data-driven systems of care that save more lives.”


In part 1 of this series on systems concepts, we heard Dr. Ackoff give a wonderful explanation of what a system is. In part 2, we explored the systems thinking principle that helps us understand why having all of the best individual parts needed for a system does not necessarily get us the best system. That’s because the performance of a system is not the sum of its parts, it’s a product of their interactions. The parts all have to fit together well.

In part 3, we found that even with great parts that fit together well, you still may not have the best performing system. We explored the definition and calculation of value. We saw how the value equation uses measures of quality and cost to calculate value in a quantitative way. The best systems of care provide high quality, as measured in outcomes; and the best systems are able to do so at a low total cost, as measured in dollars. High quality combined with low total cost provides the best value – and that’s what the best of the best systems of care deliver.

Here in Part 4, we are going to revisit the systems of care concept itself and dig a bit deeper, specifically in the context of HIRTC conditions. HIRTC is the acronym we will be using here for high-risk time-sensitive conditions.

A system of care for acute ischemic strokes, for example, is a true ‘system’ as described by Dr. Ackoff. It’s primary purpose, like the other systems of care for HIRTCs, is to restore pre-event health status. But a comprehensive stroke system of care will not just try to quickly re-open the obstructed vessel – it will also seek to address the challenges of rapid recognition of an acute onset stroke by patients and bystanders; get them to seek immediate medical care – preferably via 9-1-1; provide protocol guidance for the EMS response to include stroke screening; and if stroke is suspected, to do a severity assessment for identification of likely large vessel obstruction cases; then guide decisions about the most appropriate destination hospital; effectively communicate findings from the field to the receiving hospital; have the hospital stroke team activated prior to ambulance arrival; consider routing the patient directly to the CT scanner upon hospital arrival to save more time if it’s appropriate to do so; then make the appropriate decision about acute treatment with thrombolytics and or mechanical thrombectomy; provide any other acute supportive care as needed after restoring flow; and then provide rehabilitative services to address any neurological deficits that may have developed.

That stroke system of care scenario involves lots of different providers. Organizations that provide public education on stroke recognition and accessing the 9-1-1 emergency response system; the primary 9-1-1- communications centers which are typically operated by law enforcement agencies; the secondary 9-1-1 communications centers used for emergency vehicle dispatch at the fire departments and or ambulance services; non-transport medical first response often operated by the fire department or other rescue squad organizations; the ambulance service; the emergency department; the stroke service of the hospital; radiology department; hospital laboratory; hospital pharmacy; in-house rehabilitation service; and the discharge planning service – not to mention all of the ancillary support services that contribute to care. As a true system, all of those parts are needed to constitute the entirety of the stroke system of care.

Some even extend the bounds of their system of care activities to address secondary objectives of preventing the stroke for happening in the first place with primordial and primary prevention efforts on the front end; and another secondary objective for prevention of subsequent strokes via secondary prevention on the back end. If pre-event health status cannot be fully restored, there may also be a secondary objective of providing the best quality of life possible through long term care – and that’s also part of the system of care.

In any case, there are lots of different organizations, lots of different teams and functions within those organizations, lots of hand-offs, lots of communications needs – and lots of opportunities to do each part well and connect it to the next part well – or not so well. That’s why the design, operation, and improvement of our systems of care need to address the whole systems of care. To do that well, we need to find ways to measure how well the overall systems of care are performing in terms of quality, cost, and value – and then apply quality assurance, quality improvement, and research methodologies to continuously seek out ways to elevate systems of care performance over time.

Systems of care – it’s a big issue. It needs more attention. We need to look outside of our stovepipes and see the bigger picture. I hope this helps wipe some of the bugs and grime off of your windshield so this bigger picture of systems can come into better focus.